Electroencephalography as a Biomarker of Prognosis in Acute Brain Injury.

Electroencephalography (EEG) is a noninvasive tool that allows the monitoring of cerebral brain function in critically ill patients, aiding with diagnosis, management, and prognostication. Specific EEG features have shown utility in the prediction of outcomes in critically ill patients with status epilepticus, acute brain injury (ischemic stroke, intracranial hemorrhage, subarachnoid hemorrhage, and traumatic brain injury), anoxic brain injury, and toxic-metabolic encephalopathy. Studies have also found an association between particular EEG patterns and long-term functional and cognitive outcomes as well as prediction of recovery of consciousness following acute brain injury. This review summarizes these findings and demonstrates the value of utilizing EEG findings in the determination of prognosis.

Anti-MOG associated disorder-Clinical and radiological characteristics compared to AQP4-IgG+ NMOSD-A single-center experience.

BACKGROUND: The discovery of two immunoglobulin G (IgG) antibodies against aquaporin 4 (anti-AQP4) and myelin oligodendrocyte glycoprotein (anti-MOG) has led to the distinction of the disorders anti-AQP4 immunoglobulin G positive neuromyelitis spectrum disorder (AQP4-IgG+ NMOSD) and anti-MOG associated disorder (MOGAD). Different clinical and radiological features have been proposed to distinguish these two demyelinating CNS diseases. METHODS: This is a single-center retrospective review at the University of Florida (UF) including all patients with the diagnostic code ICD G36 ("other acute disseminated demyelination") from October 2015 to January 2020 (n=141) and all charts included in the clinical NMOSD database of the UF Division of Neuroimmunology (n=36). A total of 151 cases were reviewed for presence of anti-MOG and anti-AQP4 antibodies and NMOSD diagnostic criteria. Differences in MOGAD and AQP4-IgG+ NMOSD were compared. RESULTS: Of the 151 reviewed patient charts, 11 were consistent with MOGAD and 43 with AQP4-IgG+ NMOSD. Patients with MOGAD were significantly younger at symptom onset compared to patients with AQP4-IgG+ NMOSD (14 [1-33] years vs. 37 [6-82] years; p=0.005). In comparison with AQP4-IgG+ NMOSD, optic neuritis in MOGAD was more frequently associated with bilateral optic nerve involvement: (6/11 [54.5%] vs. 6/43 [13.9%]; p=0.009) and fundoscopic presence of optic disc edema (5/11 [45.5%] vs. 3/43 [7%]; p=0.006). Perineuritis was a common radiological feature in MOGAD (present in 4 cases). In case of myelitis, there was more frequent involvement of the conus medullaris in MOGAD (4/11 [36.4%] vs. 2/43 [4.7%]; p=0.012). Symptomatic cerebral syndrome with supratentorial white matter lesions was seen in MOGAD patients with pediatric onset (pediatric onset: 4/6 [66.7%] vs. adult onset: 0/5 [0%]. In MOGAD, evidence for combined central and peripheral demyelination and increased intracranial pressure was present in one patient each. A preceding inciting event (illness/postpartum) was more frequently identifiable in MOGAD (4/11 [36.4%] vs. 4/43 [7%]; p=0.045). Disability as calculated on the Expanded Disability Status Scale was less severe in MOGAD compared to AQP-IgG+ NMOSD (most severe presentation: 5 [2-7] vs. 7 [1-10]; p=0.015; most recent assessment: 2 [0-5] vs. 5 [0-10]; p=0.045) and patients were more likely to respond to treatment of acute attacks with corticosteroids and/or plasmapheresis (Clinical Global Impression-Global Change scale: 1 [1-4] vs. 3 [1-6]; p=0.001). INTERPRETATION: The study confirms that simultaneous bilateral optic neuritis, presence of optic disc edema, transverse myelitis with conus involvement and a less severe disease course are distinctive features of MOGAD.

STN Versus GPi Deep Brain Stimulation for Action and Rest Tremor in Parkinson's Disease.

OBJECTIVE: To investigate the effects of subthalamic nucleus (STN) and globus pallidus internus (GPi), deep brain stimulation (DBS) on individual action tremor/postural tremor (AT) and rest tremor (RT) in Parkinson's disease (PD). Randomized DBS studies have reported marked benefit in tremor with both GPi and STN and DBS, however, there is a paucity of information available on AT vs RT when separated by the surgical target. METHODS: We retrospectively reviewed the 1-year clinical outcome of PD patients treated with STN and GPi DBS at the University of Florida. We specifically selected patients with moderate to severe AT. Eighty-eight patients (57 STN and 31 GPi) were evaluated at 6 and 12 months for changes in AT and RT in the OFF-medication/ON stimulation state. A comparison of "response" was performed and defined as greater than or equal to a 2-point decrease in tremor score. RESULTS: STN and GPi DBS both improved AT at 6- and 12-months post-implantation (p < 0.001 and p < 0.001). The STN DBS group experienced a greater improvement in AT at 6 months compared to the GPi group (p = 0.005) but not at the 12 months follow-up (p = 0.301). Both STN and GPi DBS also improved RT at 6- and 12-months post-implantation (p < 0.001 and p < 0.001). There was no difference in RT scores between the two groups at 6 months (p = 0.23) or 12 months (p = 0.74). The STN group had a larger proportion of patients who achieved a "response" in AT at 6 months (p < 0.01), however, this finding was not present at 12 months (p = 0.23). A sub-analysis revealed that in RT, the STN group had a larger percentage of "responders" when followed through 12 months (p < 0.01). CONCLUSION: Both STN and GPi DBS reduced PD associated AT and RT at 12 months follow-up. There was no advantage of either brain target in the management of RT or AT. One nuance of the study was that STN DBS was more effective in suppressing AT in the early postoperative period, however, this effect diminished over time. Clinicians should be aware that it may take longer to achieve a similar tremor outcome when utilizing the GPi target.

Corticosteroids lead to short-term improvement in cerebral amyloid angiopathy-related inflammation.

BACKGROUND: Cerebral amyloid angiopathy - related inflammation (CAA-ri) is an uncommon manifestation of CAA. METHODS: Single-center, retrospective review of all charts with ICD-code I68.0 (CAA) from 2/2/2016-1/1/2020. RESULTS: Of 152 CAA cases, 13 (8.6%) were consistent with CAA-ri. Corticosteroid-treatment led to short-term reduction in modified Rankin Scale scores (2.6 ± 1.4 vs. 1.6 ± 1.5; p = 0.01) and T2/FLAIR lesion volume (78.1 ± 52.2 cm3 vs. 30 ± 30.9 cm3, p < 0.01) as well as short-term improvement in post-treatment Clinical Global Impression - Global Change scores compared to pre-treatment scores (clinical: 6 ± 1 vs. 2.6 ± 1.3, p = 0.03; radiological: 4.6 ± 1.9 vs. 1.2 ± 0.4, p = 0.03). INTERPRETATION: Corticosteroid-treatment leads to clinical and radiological short-term improvement (class IV evidence).

Acute Cerebral Ischemia Temporally Associated with Marijuana Use.

The cerebrovascular effects of marijuana use are not well described. With increasing legalization of cannabis for medical and recreational use in North America, identification of potential risks of the drug is necessary. We present the case of a 31-year-old man who had two ischemic infarctions in different vascular distributions, without other identifiable etiology, which were temporally associated with marijuana use. We additionally identified the level of metabolites in his system and discussed the need for a systematic description of these cases to determine whether a dose-dependent effect exists.

Management of Blunt Cerebrovascular Injury.

PURPOSE OF REVIEW: This review provides an updated summary of blunt cerebrovascular injury (BCVI) to guide clinicians in its early diagnosis and prevention and treatment of stroke associated with such injury. RECENT FINDINGS: Untreated BCVI causes stroke in 10-40% of patients, but more than half will not present with stroke symptoms initially. Risk of stroke is highest in the first 7 days, with a peak in the first 24 h. Computed tomography (CT) angiography is currently the screening modality of choice, although digital subtraction angiography may still be required in some cases. Antithrombotic therapy is the mainstay of treatment and has proven safety in trauma patients. In carefully selected patients, endovascular intervention may also be beneficial. BCVI is a potentially preventable cause of stroke. A high index of suspicion is needed as emergent screening during initial evaluation can provide a window for stroke prevention. Screening all patients with injuries that would otherwise prompt CT scans of the neck or chest is recommended. Treatment is guided by grade of injury. Early treatment with antithrombotics has been shown to be both effective and safe.

Nanoparticles and stem cells - has targeted therapy for aneurysms finally arrived?

Until recently, endovascular management of intracranial aneurysms has focused on mechanical and hemodynamic aspects: characterizing aneurysm morphology by angiogram, mechanical obstruction by detachable coils, and flow diversion with endovascular stents. Although now common practice, these interventions only ward off aneurysm rupture. The source of the problem, disease of the vessel wall itself, remains. New imaging technology and treatment modalities, however, are offering great promise to the field. In this review, we outline several new developments in the recent literature and pose potential adaptations toward cerebral aneurysms using them. The incidence, presentation, and contemporary endovascular treatment for aneurysms are first reviewed to lay the groundwork for new adaptations. Nanoparticles, including ultrasmall supraparagmenetic iron oxide particles (USPIOs), are next explored as a novel mechanism of predicting aneurysm wall instability and as an agent themselves for aneurysm occlusion. Cellular transplant grafts, bone marrow-derived stem cells (BM-MSCs), and endothelial progenitor cells (EPCs) are then investigated, with the role of cellular differentiation, chemokine secretion, and integration into the injured vascular wall receiving particular emphasis. Several promising translational papers are next discussed, with review of multiple studies that show benefit in aneurysm treatment and endovascular stenting using these agents as adjuncts. We next adapt these research findings into several potential applications we feel may be promising directions for the aspiring researcher. These new treatments may one day strengthen the arsenal of the endovascular neurosurgeon.